Evaluation of endoscopic variceal band ligation sessions in obliteration of esophageal varices.

Objective
To determine number of sessions of Endoscopic variceal band ligation required to obliterate the esophageal varices.


Methods
This study was conducted at Civil Hospital Karachi between June 2018 to April 2019. All patients undergoing endoscopic Variceal Band Ligation (EVBL) were inducted. Number of sessions of band ligation required to obliterate the varices were recorded. Number of EVBL sessions were correlated with Child-Pugh's Score and etiology of CLD by χ2 test, while it was compared with duration of Chronic Liver Disease (CLD) by One-way ANOVA test.


Results
One hundred ninety-two patients fulfilling selection criteria were admitted after informed consent. These included 101 (52.6%) males and 91 (47.4%) females. Most common cause of cirrhosis was HCV (66.7%) in our patients. Most of the patients were in Child Class-B (71.9%). Majority of patients (52.6%) underwent 3 sessions of EVBL while 68 (35.4%) underwent 4 sessions of EVBL. Duration of CLD was analyzed with number of sessions of EVBL by One-Way ANOVA test and it showed significant more sessions of EVBL were done with longer duration of CLD (p <0.001).


Conclusion
Most patients underwent 3-4 sessions of EVBL for obliteration of varices. Number of EVBL sessions increased significantly with duration of disease.


INTRODUCTION
Variceal bleeding is a serious life-threatening complication of portal hypertension. 1 Portal hypertension is part of a dynamic process triggered by chronic liver disease. There are many etiologies of chronic liver disease, the most common being chronic viral hepatitis in our part of the world and alcohol in the western world. [2][3][4][5] In cirrhosis there is an increase in the intrahepatic vascular resistance as a result of fibrosis and a rise in the vascular tone of the hepatic microcirculation. 6 The rise in portal pressure causes collateral circulation to develop as a result portal blood is diverted into the systemic circulation. In decompensated cirrhosis portal hypertension is a serious problem and it may present as ascites, splenomegaly and esophageal varices. 3

Original Article
Evaluation of endoscopic variceal band ligation sessions in obliteration of esophageal varices Hepatitis C (HCV) is the commonest cause of cirrhosis in our part of the world. 5 About 50% of the cirrhotic patients develop esophageal varices and among them 35% will die in their first episode. 7 There are different grades of varices and they may be classified as small, medium and large varices. 8 Endoscopic Variceal Band Ligation (EVBL) is effective mode to treatment not only to arrest active bleed, but in eradication of varices. Multiple sessions of EBVL are required to obliterate the varices. 9 Successful obliteration of varices decreases the likelihood of variceal bleed and thus decreases morbidity and mortality. 5 Obliteration of varices is an important milestone in management of cirrhosis. We searched Medline via PubMed and local index PakMediNet for publications on this topic which showed very scanty data worldwide and none from Pakistan. There is lack of information on this topic and need to conduct study on this aspect of liver disease.
Our objective was to determine the number of sessions of EVBL required to eradicate the esophageal varices in cirrhotic patients. This study will help in better understanding of this disease in our settings and better formulation of management and prediction plans in our population.

METHODS
This study was conducted at Civil Hospital Karachi between June 2018 to April 2019. Patients satisfying inclusion/exclusion criteria were included after informed written consent. Approval (IRB-1030/DUHS/Approval/2018/80 dated May 31st, 2018) was taken from the Institutional Review Board of Dow University of Health Sciences. All patients undergoing endoscopic Variceal Band Ligation (EVBL) were inducted. Number of sessions of band ligation required to obliterate the varices and number of bands applied per session were recorded. Patients having gastric varices, patients with a history of sclerotherapy or previous band ligation, rebleed after EVBL, patients with hepatic encephalopathy, patients with a platelet count of <50000/mm 3 , INR of >1.8 were excluded. EVBL sessions were performed by faculty who have certified training in doing EVBL and related endoscopic procedures. All patients were started with Tab Carvidalol 6.25 mg bid next day of EVBL unless there was any contra-indication. Those with contraindications were excluded from analysis but continued treatment and further sessions. Varices were defined as obliterated if there were no varices on visual inspection on endoscopy or were too small for EVBL.
All the patients were evaluated by one of the authors about clinical history and examination. The blood tests performed were Blood CP, PT/INR. All EVBL were performed in a single endoscopy unit using Olympus video scope GIF 180 by experienced gastroenterologists. First vitals were checked, and patients were sedated with midazolam intravenously according to the weight of the patient. A screening endoscopy was done and if medium to large size esophageal varices were present then bands were applied by using multi-load ligature device. Patient were observed for an hour after the procedure and discharged with clear written advice. Patients were advised to revisit after 3 weeks with fresh complete blood count and prothrombin time for next session of endoscopy and if needed then band ligation.
Grading of esophageal varices is given as under which is based on approximate size of standard open biopsy forceps is equal to 5 mm: 6 • Small: < 5 mm • Large: > 5 mm Child Turcotte Pugh (CTP): In this classification two clinical sign, i.e., ascites and hepatic encephalopathy and three laboratory parameters, i.e., bilirubin, serum albumin and INR are included. They are classified according to the points system and is designated as class A (5-6 points), class B (7-9 points) and class C (10-15 points). Sample Size: Using WHO calculator Sample size was calculated by taking prevalence as 22.1% for two sessions, with margin of error 8%. The power of this analysis is 95% and p-value of 0.05. The sample size was estimated to be 104 patients. Sample technique was non-probability consecutive sampling. Data Analysis Procedure: Data was entered in SPSS version 25.0. Frequencies and percentages for gender, Child-Pugh's Class, etiology and number of sessions of EVBL were done. Mean ±SD were reported for age and duration of CLD. Mean age was compared with gender by student's t-test. Number of EVBL sessions were correlated with Child-Pugh's Score and etiology of CLD by χ 2 test, while it was compared with duration of CLD by One-way ANOVA test. Level of significance was set at ≤0.05.  Table-I. Number of sessions of EVBL was tested for significance with Child-Pugh's Class and Etiology of CLD by using χ 2 -test. Test reveal 8 (53.3%) cells had expected value of <5 so Likelihood Ratio was calculated, and it showed significantly higher number of EVBL done in Child Class-B (p = 0.035). Similarly, significantly higher frequencies of HCV were found as etiology in our study (p = 0.013). Number of sessions were compared with duration of disease and age by One Way ANOVA.

One
It showed significant more sessions of EVBL were done with longer duration of CLD (p <0.001) while no significant difference was found with age (p = 0.967). Details are given in Table-II. Sub-analysis of ANOVA between sessions of EVBL was done using Games-Howell Method. It showed following results in between different sessions of EVBL: • Two/Three: Non-significant • Three/Four: Significant • Four/Five: Non-significant • Five/Six: Non-significant Details are given in Table-III.

DISCUSSION
Cirrhosis is a leading cause of mortality and morbidity worldwide. Bleeding from esophageal varices is one of the most serious complications of cirrhosis having a high mortality. 10 Patients who survive a first episode of variceal bleeding have a 60% risk of experiencing rebleed. Therefore treatment to prevent first episode of variceal haemorrhage is of utmost importance and all patients surviving a variceal bleed must receive treatment to prevent rebleeding. 1 EVBL is the mainstay in the management of esophageal varices.

Endoscopic variceal band ligation
In our study we aimed to find out the number of sessions of EVBL required to obliterate esophageal varices. Successful eradication was taken as disappearance of varices or presence of small varices which could not be ligated. In our study majority of patients were from Child-Pugh Class-B and the majority of patients required 3-4 banding sessions to obliterate the esophageal varices in 93.2% of our patients. Our findings were supported by a study by Khattak AB in which majority of patients achieved complete eradication after 3 sessions of band ligation. 11 In a study by Lahbabi M et al. it was reported that obliteration of the varices was achieved in 89.6% of patients with 3±1.99 sessions of band ligation. 12 There are variable views regarding schedule of EVBL sessions. We followed flexible 2-4 weeks' interval in EVBL sessions. While some favor's weekly versus bi-weekly schedule and others favor bi-monthly schedule. 13,14 Pain and post banding ulcers were found more frequently in short interval sessions protocols but late obliteration of varices occurred with long interval protocols. Shrestha B et al. in their study reported that in the majority of their patients, varices were eradicated after 2 sessions of band ligation and 24.1% of patients required just 1 session of EVBL whereas in our study in none of the patients the varices were obliterated after 1 session. 10 Haris Alvi et al.